0008-149 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of,the Business and
Professionals Code, and my License is in full force and effect.
License # Lia Class Exp. Date
x.,570 4°
Date 7�`' a ' Signature of Contractor t'
OWNER -BUILDER DECLARATION 111
I hereby affirm -under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
as owner of the property, or my employees with .wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec: 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to.construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
() I.have and will maintain a certificate,of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
have.and will -maintain workers' compensation insurance; as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATE FUND Policy No. . 046-OOU7330
(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Californian nd agree that if I should become
subject to th a workers' compensation provisions of Section 3700 .of th Labor
Code, I shall forthwith comply with those provisions. r
Applicant?
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $106,'000; in
addition to the cost of compensation, damages as provided for in Section 37,06
of the Labor Code, interest and attorney's fees. t
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application:
1. Each person upon whose behalf this application is made & each person at
whose request and'for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null'and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of.work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply'with all -„City, and State laws relating to the building.-,.,
construction, and hereby authorize representatives,of this City to enter upon a
the above-mentioned property for inspection p ru poses °
Signature'(Owner/Agentj-~Fn `"`ate
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 00N-149 TRACT
/jJ �y q ` ry p G' ry y
f �•” f' j `w.. t - Wa? Ay Qi1.a3V �" 29-m
JOB SITE i - -
ADDRESS.. 49-cas vy m PrwIma A
APN
9�400-OM
OWNER
CONTRACTOR / DESIGNER / EN (NEER
TIN -DES _,'KTD.9M0P1 T ..
;��. � CO������ON
PO BOX 1716
79-295 RA CI --10 LA QI.�.I TAD1t
L4 Q€TWA CA 9225:
1~.A QUDq-TA. CA 92253
(760)771.1941 CBIS 2996.
USE
OOFFq��P��ERRyyMIT yy�,h(� �n��f}'j�y �y 7
t INGLA 1',CYLgA.Id,.• ]. MM sI„ NG
J .
SPID- LMA 16 7?3.AN:Mlft - PERMIT 001t$ NOT INCLUDE SLOC:A:WALLS
Ok POOL, %% PLAN CHECK REE REDUCTION FOR MULTIPLEISWAN:K' r
OF ShML PLAN T'Y'PE
CUSTOM CONSTRUCTION 4,243.00 3F
PORCH/PATIO 592.00 SP
GARA.CII:1C„ ARPORT (13F') 13,916100
E$rnW.TFD COST OF COMMI Ci(".i7fON
3151,: ft30
Pk1 Mrf 1t T� 9iTMARY
C01'I IT ROCTION 1;Is,E 101.000-418-000 $1¢521150
PLAN C:HWK F'ZE 101.00O.439-318 $309,73
MECHANICAL FATE 101.000-421,000 $I36 S0
F
&L.ECTR)CAL" 101.000-420-000 $ 96:'71
�;
PLUMBING 1ZF, 101.060-419-000 $205,00
, a
STRONG MOTION K1?2, - :i2.WID 101-000-24.1.000 $35.14
}I3Alllk101;isF. 101e000-423.000 $20,00
ImVELOPER IMPACT FEE $1,907.610
a., V: Ys
ART IN PUBLIC PLACK4 - RE IL 701-000455.000 $M47rn
SUB -TO AL LOADS'1TLUC71G�A1,AAT1,51�1'..AN �1�}:'
$4,159.05
IaZ'33 P"r -P,A1i TWO
$1'0100
!!. L. IrAL . ..Mu FIMS 1 VE 190W
tMt¢F7u i�
RECEIPT
DATE kk ;t
BYa j
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
— —p
F.A.U.
Framing
Compressor
Insulation
%
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior lath
_ �e
Drywall - Int. Lath
'G
Final
Final
BLOCKWA
_
PROVALS
_
POOL PAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral
Sewer Connection
_
O.K. for Finish Plaster
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power ,
Final
Utility Notice (Perm)
COMMENTS: